The Voice of Podiatrists

Serving Over 10,600 Podiatrists Daily

January 18, 2008 #3,144 Editor-Barry Block, DPM, JD

A service of Podiatry Management http://www.podiatrym.com
E-mail us by hitting the reply key.
COPYRIGHT 2008- No part of PM News can be reproduced without the
express written permission of Kane Communications, Inc.

To ensure daily delivery of PM News, we recommend that you add bblock@podiatrym.com to your address book and/or to any anti-spam software you have. This will prevent PM News from either being rejected by your provider or winding up in your spam, bulk, deleted, or junk mail folder.

New Fibers Replace Cotton as Best Choice For Winter: Robertozzi

.

When it comes to winter, it's the socks. Feet get cold just like the rest of our bodies in the winter, and selecting the right socks can go a long way in keeping those dogs toasty.

.

Dr. Christian Robertozzi

.

Cotton socks are so yesterday. Fibers, such as silver and copper, are now woven into winter socks to shield feet from hot and cold temperatures, but they also have anti-microbial properties to keep fungus and foot wounds at bay, said Christian Robertozzi, president of the American Podiatric Medical Association."Winter socks are designed to provide warmth and protect the feet against excessive moisture," he says.

.

The podiatry association provides a seal of approval for certain brands of socks that meet high standards for winter use. Among these, it recommends SmartKnit's Seamless Socks with X-Static or Renfro's Copper Sole Socks.

.

Source: Pittsburgh Post-Gazette [1/16/08]

16 Month Sentence for Retired CA Podiatrist Who Molested 5 Year Old

Alan Lawrence Ager, 60, received the maximum sentence in a hearing before Marin Superior Court Judge Kelly Simmons. Prosecutors sought the full 16-year term, said Deputy District Attorney Dorothy Proudfoot.

Dr. Alan Lawrence Ager (Photo: Robert Tong)

Ager was arrested in January 2007 on allegations he inappropriately touched a boy on at least 30 occasions between October 2005 and December 2006. At a preliminary hearing last May, a sheriff's detective testified that Ager told investigators that he inappropriately touched a young boy and wanted to be caught.

Ager, a former director of the Marin Alliance for Medical Marijuana, has been entangled with authorities off and on for the past decade. In 1999, he was sentenced to a year in jail for growing hundreds of marijuana plants he said were for patients in need of medical pot.

Source: Gary Klien, Marin Independent Journal [1/16/08}

Congress To Resume Crafting Medicare Reform Package

Congressional aides at a forum on Wednesday said they are optimistic that Congress can pass Medicare legislation this year that likely would stop for 18 months a 10.6% cut to Medicare physician fees, CQ Today reports. The fee cut is scheduled to go into effect on July 1 (Armstrong, CQ Today, 1/16).

President Bush last month signed into law a bill that delays the fee cut for six months and extends SCHIP through March 2009. The bill increased Medicare physician fees by 0.5% during that period and extended several programs that provide higher Medicare reimbursement rates to rural health care providers and hospital laboratories.

Source: CQ Today via American Health Line [1/17/08]

Query: Digital Photos in an EMR Chart

Does anyone know whether or not it is sufficient to use a quality digital picture in a EMR chart for as examples an ulcer or a wart and then not have to fully describe it in the notes? Is a picture worth a thousand words here or shall we say does it represent better or at least enough documentation for billing purposes as well as standing up in court? Could you just snap the pic and say "refer to chart for location and size?"

Peter J. Bregman, DPM, Tewksbury, MA, Footdoc@PAINFREEFEET.COM

Editor’s comment: PM News does not provide legal advice. While photodocumentation is an excellent way to complement your chart entry, using digital photos alone is problematic. Among other issues, digital images can corrupt over time, leaving one without any documentation. When using photos to document size and depth, be sure to include a ruler or other measuring device in the shot.

RE: Functional Compartment Syndrome? (Peter Smith, DPM)
From: Multiple Respondents

Dr. Smith, what you are inquiring about is most commonly called "exertional compartment syndrome" and it is usually running/ exercise induced vs. "acute compartment syndrome" - usually trauma-induced. It is not abnormal for all of the tests you've described to come back normal and it is also not uncommon for it to firstly, get diagnosed as shin splints or stress fracture.

To obtain definitive diagnosis the patient would have her compartment pressures measured (with a pressure gauge: such as the Stryker intra-compartmental pressure monitor) prior to running on a treadmill, then immediately after stopping and lastly, at 5 minutes after ceasing exercise. I typically put a healthy dose of 0.5% Marcaine subcutaneously at the sites of compartmental penetration to help mitigate what is a fairly painful stick. The values are: 15mm.Hg. at rest, 30mm.Hg. immediately after and 20 mm.Hg. 5 minutes after running. It is accepted that satisfying just one of these can make the diagnosis. Confidence of the diagnosis improves with each value achieved.

Unfortunately, for these patients the only real option, aside from ceasing painful activity, is surgical fasciotomy/fasciectomy of the lower leg. Fortunately, the procedure usually works well. If you have not done this before and or depending on your state laws for scope; I would recommend you refer her to an orthopedic surgeon who specializes in sports med. Kudos to you for at least considering this often-missed diagnosis.

Douglas Pacaccio, DPM, Yorkville, IL, drpacach@mac.com

Pre and post-exercise MRI can be useful. You can detect increased signal changes within the affected compartment if positive. Even though she is only 11 years old, a vascular w/u should be done to detect anomaly. I had a similar case with a 25 year old healthy male; end-result was SFA occlusion.

Thomas A. Brosky II, DPM, Oakwood GA, dr.brosky@charter.net

I would seek TCOM studies to see if there is indeed a hypoxic component. Our hyperbaric service, at a Level-1 Trauma Center evaluates compartment syndrome in all ages and of all etiologies. Many times, the TCOM studies have proven invaluable in guiding a prompt, effective treatment plan. Lastly, go with another series of MRI/CT studies. Films are only as accurate as the radiologist reading them. We all have our stories of misread diagnostic tests! Rely on your own instincts..and do not do what majority of clinicians do by "relying" on an opinion when another opinion may be more accurate!

Alan J. Cantor, DPM, East Meadow, NY, ajcdpm@aol.com

RE: Width of Margins For Excision of Malignant Lesions (Brent Rubin, DPM)
From: Bryan C. Markinson, DPM

Dr. Rubin posed the question of adequate margins of resection for melanoma and squamous cell carcinoma. The answer to this question is not as straightforward as it may seem. Firstly, recommendations are changing and not universally agreed upon. For squamous carcinoma, location is critical, as the answer for head and neck lesions is not the same as extremity lesions. Additionally, recurrent squamous cell carcinoma is treated differently than primary lesions. Once biopsy proven, definitive treatment and follow-up of both melanoma and squamous carcinoma is probably out of the normal experience of most podiatric physicians.

In general, a 4-mm. margin of normal tissue is recommended with lesions smaller than 2 cm., well-differentiated, without subcutaneous fat invasion on the extremities. For lesions larger than 2 cm., invasive to fat, and in high-risk locations, which the foot is considered, a 6-mm margin of normal tissue is recommended. The depth of the excision should always include a portion of the subcutaneous fat. Mohs micrographic surgeons argue that they can get more reliable margins of resection while sparing tissue.

For melanoma, the old school recommendations were always to resect 5 cm. margins. Currently, the recommendations are 1 cm. for every millimeter of depth. The role of Mohs surgery for melanoma is controversial but expanding. Again there is argument that they can reliably get clear margins of resection with less tissue loss. I believe that this technique may be more applicable to lesions on the eyelids, penis and vulva, and never applicable to foot lesions (my opinion only). Moh's surgeons rely on frozen tissue sampling during their procedures, known to obscure details in melanoma diagnosis. In my hospital, a study of enhanced staining techniques have recently resulted in an actual upgrading of previously signed out in-situ lesions to invasive ones at what our dermatopathologist believes is a very disturbing number. These findings have been submitted for publication. It is therefore important to have expert dermatopathological analysis of these lesions prior to planning wide excision to as best as possible determine the extent of the tumor.

In both instances, the planning of WLE and follow-up is truly a multidisciplinary effort and most literature supports a hospital-based approach.

Bryan C. Markinson, DPM, New York, NY, Bryan.Markinson@mountsinai.org

RE: Renting Treatment Rooms to Physicians (Hal Ornstein, DPM)
From: Neil Levin, DPM, Jason Gross, MHA

I have been renting "time share space" in a clinic for more than 5 years. It has been a perfect way for me to have a part time presence without the capital expense of opening an office. I have the use of 2 rooms with power chairs, fax, my own phone line, chart storage, etc. I bring my own supplies (a locked storage area is provided) and office staff. I pay $600 per month for a half day segment. I do this twice a week. I also get a large number of referrals from the internists that own the building. The space is also used by urology, pain management, a vein specialist, cardiology and others. If you provide a turn-key situation, you should have no problem renting half day segments for similar money. It is a win-win situation.

Neil Levin, DPM, Sycamore, IL, drfeet1@aol.com

We are in the beginning stages of negotiations with an MD and a couple of PA’s that are interested in a full-time lease. We will share a common reception room and some front office staff and they will be using some of our equipment (treatment tables, autoclave, scales etc.) According to our attorney, since there will likely be referrals between the other physicians and our practice, we cannot just merely include the infrastructure into the space rental agreement. We will either set up separate agreements for the personal services, the equipment and the space, or put it all into one agreement but have three separate components. With all of the other Stark considerations I would suggest you contact a healthcare attorney to help you draft documents that are in compliance with all of the new laws, especially since phase lll of Stark ll just went into effect on 12/05/07.

One challenge I am having is how to determine the rent for the use of the equipment. Any suggestions on that would be greatly appreciated.

Jason Gross, MHA, Forest City , NC, jgross@footandanklenc.com

Editor’s Comment: PM News does not supply legal advice. One parameter often cited is “Fair Market Value” which implies that you are not deeply discounting your fee as an inducement for referrals. There are several ways to arrive at this figure, including charging what a leasing company would charge or finding similar rental fees in your area. As with all Stark matters, consult a healthcare attorney well-versed in this complex area of law.

RE: Office Attire (Alan Mauser DPM)
From: Multiple Respondents

With the recent conversation regarding appropriate office attire, I was reminded of this article I read a few months ago (http://www.msnbc.msn.com/id/20821636/):

British hospitals are banning neckties, long sleeves and jewelry for doctors — and their traditional white coats — in an effort to stop the spread of deadly hospital-borne infections, according to new rules published Monday. Hospital dress codes typically urge doctors to look professional, which, for male practitioners, has usually meant wearing a tie. But as concern over hospital-born infections has intensified, doctors are taking a closer look at their clothing. “Ties are rarely laundered but worn daily,” the Department of Health said in a statement. “They perform no beneficial function in patient care and have been shown to be colonized by pathogens."

Michael Cornelison, DPM, Cupertino, CA, drcornelison@yahoo.com

There are times when you need to dress for success, but I have found that you need to be comfortable within your own office. I did the button down shirt, ties, and argyle socks for 9 years. I have done the complete opposite now... wearing nothing other than scrubs and running shoes for the last 10 years. I grew my hair longer, and wear a beard. I have found no difference, in fact... the more comfortable I became, the less intimidated the patients were. You will notice, that more patients will start asking you, "have you been in surgery?", or "have you been to the hospital today?" Your confidence will be the most important thing. If you like lab coats, go for it. I just find them too stuffy here in Florida. I just had my name printed on the scrubs, if you like to feel important.

Carl Ganio, DPM, Vero Beach, FL, drcarlganio@bellsouth.net

I did a month-long survey in my office a few years back in my suburban area where I practice. The conclusion was patients don't care too much how you dress or if you wear scrubs, or use a lab coat. When asked, they said they thought of me more as a surgeon with my scrubs on than when I wore a shirt and tie. Often when I wear scrubs, they will remark, "am I performing surgery today?" or something to that effect. So I guess it depends on your patient population, as well as how you would like to be perceived.

Peter J. Bregman, DPM, Tewksbury, MA, Footdoc@PAINFREEFEET.COM

ASSOCIATE POSITION – NEW JERSEY

Established practice in Ocean County seeks hardworking, ethical, energetic and well-trained (PSR 24/36) individual. Practice provides EMR, digital x-rays, ultra-sound and NCV’s. Must be willing to do all aspects of podiatry! Competitive salary and benefits package. E-mail CV to NJFeet@aol.com

ASSOCIATE/BUYER WANTED – SOUTHERN CALIFORNIA

Unique & rare opportunity for a Japanese-bilingual podiatrist. Seeking motivated, conscientious, and ethical individual with excellent people skills for associate leading to ownership or a buyer for immediate purchase. No nursing homes & well-established referral base. Serious inquiries only. E-mail letter of introduction, photo and CV to: socaldpm@gmail.com

ASSOCIATE POSITION- CONNECTICUT

Established Practice looking for PSR 24/36 trained surgeon. Must have experience and be responsible for all surgical cases for the
practice. EMR and digital x-ray in new 6-treatment room office.
Hospital privileges available. Connecticut has a new ankle law for the
Properly-trained DPM. Competitive salary, benefits, and bonus. Great area to raise a family. Fax resume to 860 243-5790

PODIATRISTS NEEDED - CHICAGO --NORTHWEST INDIANA

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists. We are located in Chicago and Northwest Indiana. Full and part time positions are available. Competitive Compensation including malpractice. Contact Scott Schneider. Phone-773-342-4201 FAX 773-486-3548-E-Mail sschneider@homephysicians.com -- www.homephysicians.com

ASSOCIATE WANTED – NEW YORK IMMEDIATE OPENING

Busy multi-dimensional practice; 70 miles north of New York City . Currently five (5)-doctor practice. looking to expand – all phases of podiatric medicine. contact: (845) 454-8308 EXT: 106

PRACTICE FOR SALE - SOUTH CAROLINA

Upstate SC practice of 25 years. Retiring. High volume, high grossing. 60% routine foot care, 40% surgery. Several nursing homes. Plenty of opportunity for growth. Hospital and Surgery Center privileges. Financials available upon request. Serious inquiries only! Beautiful area. Contact: Carolinafootdoctor@yahoo.com

ASSOCIATE POSITION- KANSAS CITY, MO

Excellent opportunity for a hard working, ethical podiatrist to join a vibrant, successful and growing podiatric medical and surgical practice. Dedicated, supportive staff with strong marketing and medical knowledge. Must be board eligible/certified. PSR/24. Partnership opportunity. Competitive salary, bonus structure, benefits. Wonderful place to raise a family. Fax CV to 816-455-8901

ASSOCIATE POSITION – VIRGINIA

Must have Virginia license. Requires 24 to 36 month Residency. Permanent position with potential buy in. Includes all phases of Practice excluding nursing homes. Competitive Salary and Benefit package. Please send Resume including salary requirements and availability date to needpodjob@yahoo.com

PARTNER WANTED FOR GROUP PRACTICE LOCATED 1 1/4 HOURS NORTH OF NYC

BE AT THE RIGHT PLACE AT THE RIGHT TIME. YOU CAN'T BEAT THIS OPPORTUNITY. Respond to: mhudes@footcaregroup.com

PRACTICE FOR SALE - PHILADELPHIA, PA

Six year-old well established practice averaging 300K over the past three years. Suitable for surgical podiatrist. Large referral base and surgical care. I am looking to relocate. I will stay during transitional period. Excellent Philadelphia location. Practice is still growing, allowing instant and increasing income. Hospital and Surgical Center privileges. Equipment included. Fax 215-665-9242 for details

40 year old part time practice for sale. Priced for quick sale. Please contact me at footdoc60@gmail.com. Serious inquires only, please

WEEKLY SPECIAL - One week of ads (5x) for only $85

PM Classified Ads Reach over 10,000 DPM's and Students

Whether you have used equipment to sell or our offering an associate position, PM News classified ads are the fastest, most-effective way of reaching over 10,000 DPM's. Write bblock@podiatrym.com or call (718) 897-9700 for details. THIS OFFER DOES NOT APPLY TO BUSINESSES PROVIDING PRODUCTS OR SERVICES. Note: For commercial or display ads contact David Kagan at (800) 284-5451 Ext 110.

• To Post a message, send it to:    bblock@podiatrym.com
• Notes should be original and may not be submitted to other publications or listservs without our express written permission.
• Notes must be in the following form:
  RE: (Topic)
  From: (your name, DPM)
  Body of letter. Be concise. Limit to 250 words or less). Use Spellchecker
  Your name, DPM City/State
• Subscribers are reminded that they have an ethical obligation to disclose any potential conflicts of interest when commenting on any product, procedure, or service.